Diabetes Management in Chronic Kidney Disease: A Consensus Report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO)

Abstract

People with diabetes and chronic kidney disease (CKD) are at high risk for kidney failure, atherosclerotic cardiovascular disease, heart failure, and premature mortality. Recent clinical trials support new approaches to treat diabetes and CKD. The 2022 American Diabetes Association (ADA) Standards of Medical Care in Diabetes and the Kidney Disease: Improving Global Outcomes (KDIGO) 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease each provide evidence-based recommendations for management. A joint group of ADA and KDIGO representatives reviewed and developed a series of consensus statements to guide clinical care from the ADA and KDIGO guidelines. The published guidelines are aligned in the areas of CKD screening and diagnosis, glycemia monitoring, lifestyle therapies, treatment goals, and pharmacologic management. Recommendations include comprehensive care in which pharmacotherapy that is proven to improve kidney and cardiovascular outcomes is layered on a foundation of healthy lifestyle. Consensus statements provide specific guidance on use of renin-angiotensin system inhibitors, metformin, sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, and a nonsteroidal mineralocorticoid receptor antagonist. These areas of consensus provide clear direction for implementation of care to improve clinical outcomes of people with diabetes and CKD.

Figure 1

CKD screening and diagnosis for people living with diabetes. Screening includes measurement of both urine albumin and eGFR. Abnormalities should be confirmed. Persistent abnormalities in either urine ACR or eGFR (or both) diagnose CKD and should lead to immediate initiation of evidence-based treatments. ACR, albumin-to-creatinine ratio; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; T1D, type 1 diabetes; T2D, type 2 diabetes.

Figure 2

Risk of CKD progression, frequency of visits, and referral to nephrology according to GFR and albuminuria. The numbers in the boxes are a guide to the frequency of screening or monitoring (number of times per year). Green reflects no evidence of CKD by eGFR or albuminuria, with screening indicated once per year. For monitoring of prevalent CKD, suggested monitoring varies from once per year (yellow) to four times or more per year (i.e., every 1–3 months, [deep red]) according to risks of CKD progression and CKD complications. These are general parameters only, based on expert opinion, and underlying comorbid conditions and disease state must be taken into account, as well as the likelihood of impacting a change in management for any individual patient. CKD, chronic kidney disease; GFR, glomerular filtration rate.

Figure 3

Holistic approach for improving outcomes in patients with diabetes and CKD. Icons presented indicate the following benefits: BP cuff, BP lowering; glucometer, glucose lowering; heart, cardioprotection; kidney, kidney protection; scale, weight management. eGFR is presented in units of mL/min/1.73 m². *ACEi or ARB (at maximal tolerated doses) should be first-line therapy for hypertension when albuminuria is present. Otherwise, dihydropyridine calcium channel blocker or diuretic can also be considered; all three classes are often needed to attain BP targets. †Finerenone is currently the only ns-MRA with proven clinical kidney and cardiovascular benefits. ACEi, angiotensin-converting enzyme inhibitor; ACR, albumin-to-creatinine ratio; ARB, angiotensin II receptor blocker; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CCB, calcium channel blocker; CVD, cardiovascular disease; eGFR, estimated glomerular filtration rate; GLP-1 RA, GLP-1 receptor agonist; HTN, hypertension; MRA, mineralocorticoid receptor antagonist; ns-MRA, nonsteroidal mineralocorticoid receptor antagonist; PCSK9i, proprotein convertase subtilisin/kexin type 9 inhibitor; RAS, renin-angiotensin system; SGLT2i, sodium–glucose cotransporter 2 inhibitor; T1D, type 1 diabetes; T2D, type 2 diabetes.

Figure 4

Overcoming barriers to management of CKD in patients with diabetes. Barriers such as low CKD awareness, high complexity of care, difficulties with adhering to increasingly complex treatment regimens, and low recognition and application of guideline-directed management all contribute to suboptimal management of patients with diabetes and CKD. Proposed strategies that may contribute to improved management of patients with diabetes and CKD include implementation of multidisciplinary models of care, structured risk mitigation strategies and education, multidisciplinary educational initiatives, harmonization of clinical practice guidelines, and provision of self-management programs for patients with diabetes and CKD.